Lymphogranuloma venereum (LGV)

• LGV is a rare sexually transmissible infection (STI) that can be cured with antibiotics.
• Caused by the bacteria Chlamydia trachomatis, specifically serovars L1-3.
• In Australia, LGV is usually symptomatic and primarily affects men who have sex with men and travelers from endemic regions.

Cause

• Caused by Chlamydia trachomatis serovars L1-3
• Non-LGV genital chlamydia is caused by serovars D-K

Epidemiology:

• LGV is common in South and Central America, the Caribbean, Southeast Asia, and Africa.
• Spread to Europe, North America, and Australia, but remains rare in Australia.
• Between 2017 and 2021, less than 25 LGV notifications per year in Queensland. Only 1 notification in 2021, likely due to COVID-19 impacts.

Clinical Presentation

Symptoms:

• Primary:
  • Small, painless ulcer or sore at the site of infection (genitals, anus, rectum, or mouth).
  • Ulcer may heal in a few days without treatment but the infection persists.
• Secondary:
  • 2-6 weeks post-infection, swollen and painful lymph glands in the groin or pelvis.
  • Symptoms include fever, muscle and joint aches, and headaches.
• Tertiary:
  • Chronic proctitis, fistulae, strictures, genital oedema, scarring of vulva (esthiomene)

Clinical Presentation:

• Pain, discharge, or bleeding from the anus.
• Swollen lymph nodes in the groin area.
• Small ulcers on the genitals which may go unnoticed.

Transmission:

• Sexual contact with an infected person.
• More common in men who have sex with men and individuals from regions where LGV is prevalent.

Complications:

• Long-term tertiary sequelae are rare in Australia, but may occur with chronic untreated infection.

Special Considerations:

• The site of the primary lesion depends on the inoculation site: genitals, perianal area, or rarely in the mouth.
• Proctitis symptoms: rectal pain, bleeding, discharge, tenesmus, and changed bowel habit.
• Routine screening of asymptomatic patients is not recommended as LGV in Australia is usually symptomatic.

Diagnosis

Site/Specimen:

• Rectal swab: Chlamydia NAAT
  • Initial test in patients with proctitis symptoms
  • Clinician-collected or self-collected
  • Request form: Proctitis: NAAT. If chlamydia positive, send for LGV testing
• LGV-specific NAAT: Subsequent test on positive rectal chlamydia test in symptomatic MSM
  • Ensure laboratory sends positive samples for LGV typing to reference laboratory
• Swab from ulcers: Chlamydia NAAT
  • Initial test to investigate ulcer
  • Clinician-collected viral transport swab over lesion
  • Not routine for genital ulceration, only if high clinical suspicion of LGV

Specimen Collection Guidance:

• Clinician-collected or self-collection

Investigations:

• High rate of co-infection with gonorrhoea, syphilis, hepatitis C, and HIV
• HSV NAAT at the time of consultation
• Tests for these conditions at initial and follow-up consultations
• Syphilis serology and NAAT from ulceration areas
• Proctoscopy: Red, ulcerated, oedematous mucosa, mucopurulent discharge
• Gram stain with >20 white cells suggests LGV

Management

Principal Treatment Option:

• Situation: Suspected or confirmed LGV
  • Recommended: Doxycycline 100 mg orally twice a day for 21 days
  • Alternative: Seek specialist advice for alternative regimens

Treatment Advice:

• LGV DNA can persist in rectum up to 16 days post-treatment initiation, hence 21-day course
• Initial treatment for proctitis with LGV suspicion should also cover gonorrhoea and HSV

Other Immediate Management:

• Advise no sexual contact for 21 days during treatment
• Advise no sex with partners from the last 3 months until tested and treated if necessary
• Contact tracing
• Provide patient with a factsheet
• No need to notify health departments about LGV

Special Treatment Situations:

• Persistence of Symptoms: Check other STI tests; seek specialist advice
• Pregnancy: Seek specialist advice
• Allergy to Treatment: Seek specialist advice
• Inguinal Buboes: May require drainage; seek specialist advice

Contact Tracing

• High priority due to rarity in Australia
• Trace all partners back for 3 months before symptoms or since arrival from endemic area
• Asymptomatic partners: Trace for the last 6 months
• Refer to Australasian Contact Tracing Manual – LGV for more information

Follow-Up

• Review in 1 week:
  • Check results from initial consultation
  • Confirm treatment adherence and symptom resolution
  • Ensure contact tracing procedures are followed
  • Educate about safe practices and vaccinations as indicated

Test of Cure:

• Chlamydia NAAT at 6 weeks (3 weeks post-treatment)
• Positive test of cure: Seek specialist advice, send sample for LGV testing if positive
• Negative test: No need for further LGV testing

Retesting:

• Full STI testing at 3 months
• Follow clinical guidelines for retesting frequency, especially for MSM